1844 Pearl St, Boulder, CO 80302 303-219-8685 www ...

1844 Pearl St, Boulder, CO 80302 303-219-8685 ?

Patient Information

Name: ___________________________________________________________________________________________________________

Last

First

Middle

E-Mail Address: _________________________________ Gender: Male________Female______

Cell Phone: (____)______________

Home Phone: (____)______________

Work Phone: (____)_____________

Home Address:____________________________________________________________________________________________________

Street

City

State

Zip

Date of Birth: ___/___/______ Social Security Number: _____-____-______ Driver's License or ID Number:______________________

MM / DD / YYYY

Responsible Party Information (If Patient is a Dependent)

Name: ___________________________________________________________________________________________________________

Last

First

Middle

Relationship to Patient: _________________________

E-Mail Address: ______________________________________

Cell Phone: (____)______________

Home Phone: (____)______________

Work Phone: (____)_____________

Home Address:____________________________________________________________________________________________________

Street

City

State

Zip

Date of Birth: ___/___/______ Social Security Number: _____-____-______ Driver's License or ID Number:______________________

MM / DD / YYYY

Dental Insurance Information (Please Provide a Copy of Your Card)

Name of Primary Policy Holder: ______________________________________________________________________________________

Last

First

Middle

Primary Policy Holder's Date of Birth: ___/___/______

Primary Policy Holder's SS/ Member ID Number: _____-____-______

MM / DD / YYYY

Primary Policy Holder's Employer:________________________________________________________________________Rank:__________

Insurance Company Name:____________________ Group Number:______________ Insurance Company Phone: (____)___________

Insurance Company Address:________________________________________________________________________________________

Street

City

State

Zip

Emergency Contact Information

Local Friend or Relative not Living With You: _______________________________ Emergency Contact Phone: (____)_____________

Emergency Contact Address:_________________________________________________________________________________________

Street

City

State

Zip

Getting to Know You Why did you select our office? __________________________ Whom May we thank for referring you?___________________________ Is another member of your family already a patient with our practice? ______________________________________________________ When was your last dental visit? _____________________________________________________________________________________ When was the last time you had complete dental x-rays taken? ______________ Have you ever had any teeth removed? __________ How long have these teeth been missing? ______________________________________________________________________ How Have these teeth been replaced? Bridge Partial Denture Implants They have not been replaced

FOR ALL PATIENTS

I authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated in connection with the dental care of the patient above, and further authorize and consent that the doctor chooses and employs such assistance as he deems fit. I also understand that prior to treatment, full explanation of the procedure(s) involved will be given by the doctor and/or his staff. I agree to pay for all services rendered by this office.

______________________________________________________________________________________________________________________

__

SIGNATURE OF RESPONSIBLE PARTY

RELATIONSHIP TO PATIENT

DATE

MEDICAL HISTORY

Name:_________________________________________________Date of Birth:_____________________________

1. Have you been under the care of a medical doctor during the past two years?

Yes No

If yes, for what reason?__________________________________________

2. Are you having dental problems at this time?

Yes No

3. Do your gums bleed at any time?

Yes No

4. Are you allergic to (i.e., itching, rash, swelling or hands, feet or eyes) or

Yes No

made sick by penicillin, aspirin, codeine, or any drugs or medications? If yes, please list.______________________________________________ 5. Have you ever had excessive bleeding requiring special treatment? 6. Check any of the following which you have had or have at present:

Yes No

Heart Disease or Attack

Ulcers

HIV Positive (AIDS)

Tuberculosis (TB) Asthma Rheumatic Fever Scarlet Fever Artificial Heart Valve Heart Pacemaker Heart Surgery Artificial Joint Stroke Kidney Trouble

Shortness of Breath

Hepatitis A (Infectious)

Hepatitis B (Serum)

High Blood Pressure

Liver Disease

Heart Murmur/Mitral Valve

Diabetes

Bruise Easily

Thyroid Disease

Drug Addiction

Chemotherapy (Cancer, Leukemia) Hemophilia

Arthritis

Cold Sores or Fever Blisters

Cortisone Medication

Epilepsy or Seizures

Glaucoma

Nervousness

Pain in Jaw Joints

Psychiatric Treatment

7. Do you have any disease, condition or problem not listed? If so, please list ............................

Yes No

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

8. List all medications you are taking at this time._______________________________________________________________

9. Are you a smoker?................................................................................................................................... Yes No 10. Do you use or have you ever used recreational drugs?........................................................................... Yes No 11. Do you ever wake up from sleep short of breath? Do you snore?........................................................... Yes No 12. Do you clench or grind your teeth? ......................................................................................................... Yes No 13. Has your medication doctor ever said you have cancer or a tumor?....................................................... Yes No 14. Women: Are you pregnant Yes No If yes, what month are you due?_________________________________________

Updates (date & initial) ________ ________ ________ ________ ________ ________ ________

Our goal is to make your experience in our office exactly how you want it to be. Please take a few moments and complete this profile so we can make you as comfortable as possible.

1. Please rate, in order of value, what is most important to you in dental care: (The most important will be #1) ____Preventative Care ____Only what is necessary at the time: cost is important ____Comprehensive, quality care, best looking results ____Other__________________________________

2. Please rate, as in #1, what is most important to you in your relationship with a dentist. ____Show me what he/she is doing or planning to do so I can clearly see what is happening ____Listen to my concerns and explain what needs to be done so I can clearly hear and understand my needed treatment ____Make sure I feel comfortable and informed at all times.

3. Please circle the level of fear you have regarding dental treatment for yourself. (10 being the most fearful, 1 being

the least amount of fear)

1

2

3

4

5

6

7

8

9

10

4. Are you concerned about: (please circle yes or no)

Replacing missing teeth

Yes No

Eliminating any cavities

Yes No

Gum disease

Yes No

Bad breath

Yes No

Snoring at night

Yes No

Color of your teeth

Yes No

Appearance of your smile

Yes No

5. Please circle how important is it for you to keep your teeth for a lifetime? (10 being very important)

1

2

3

4

5

6

7

8

9

10

6. When we review your treatment plan with you, would you like to know (please check one): ____The big picture of what needs to be done ____All the treatment details along the way

DENTAL INSURANCE POLICY

Sage Dental Care proudly accepts most dental insurance plans. We file all dental insurance claims as a patient courtesy. In the event of a treatment plan, we create a reasonable estimate of patient co-payments and insurance contributions. This estimate is based on contracted insurance rates, the general breakdown of benefits obtained through the insurance verification process and our knowledge of common insurance exclusions. This estimate is not a guarantee of insurance payment. All benefit determinations are at the discretion of the insurance company and are not determined until after a claim is submitted. We provide treatment estimates as a courtesy in order to minimize the total out-of-pocket cost due by patient. All estimated patient co-payments are due on or before time of service.

Patient is responsible for any remaining account balance resulting from insurance nonpayment or underpayment. A statement will be mailed to you regarding this balance. Payment is due immediately upon receipt.

--------------------------------------PATIENT ACKNOWLEDGMENT AND AUTHORIZATION-----------------------------------------

I understand and agree to the Dental Insurance Policy stated above. I authorize all my insurance companies to make payment directly to Sage Dental Care. This assignment will remain in effect unless revoked by me in writing. I understand I am financially responsible for all charges whether or not paid by said insurance company. Further, I authorize the release of any patient information necessary to process these claims.

Signature: _______________________________________________________________ Date: _________________

APPOINTMENT DEPOSIT REQUIREMENT Sage Dental Care requires a minimum $50.00 deposit for all appointments requiring 90 minutes or more of estimated chair-time and for all appointments with a total treatment cost of $500.00 or more. The deposit operates as a credit on the patient account towards the total patient portion due on or before time of service. Sage Dental Care requires this deposit because our providers and dental assistants reserve the appointment time specifically for you at the exclusion of other patients. The deposit requirement is subject our Cancellation Policy.

The deposit requirement is reserved only for those patients choosing not to pre-pay for their services in full when scheduling the appointment.

I understand and agree.

Signature: _______________________________________________________________ Date: _________________

CANCELLATION POLICY

Sage Dental Care makes an effort to see patients on time in order to give patients they care they deserve. Therefore, we ask that you please give 48 hours notice if you are unable to keep your scheduled appointment. We reserve the right to charge a cancellation fee of $50.00 in the event of two (2) or more missed appointments lacking proper notice. We will make exceptions in the event of reasonable emergencies. I understand and agree. Signature: _______________________________________________________________ Date: _________________

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICES I, __________________________________________, have had the opportunity to review Sage Dental Care's Notice of Privacy Practices (the entire legal notice is displayed at the front desk). Signature: _______________________________________________________________ Date: _________________

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